33 NURSERY ST - BUILDING INSPECTION (2) -A -769 1 01CD
1
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised,tlar all to
Building Permit Application To Construct, Repair, Renovate Or Demolish a t�
One-or Two-Family Dwelling 470
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This Section For Official se Only - ' �'
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Building Permit Number: DateApphed: ul rm
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Building Official(Print Name). - . Signature Date
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SECTION 1:SITE INFORNIATIOW
I.I Pro ty Address: 1.2 Assessors Map&Parcel Number
� �1,�ni S k
�- I.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 'Zoning information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq III Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal❑ On site disposal system ElPublic❑ Private❑ — Check if es❑ y
SECTION 1: PROPERTY OWNERSHIP",
2.1 vnerf of ecord: 01 70
me( n u) City,State,ZIP N\
3�tc SFr t
No.and Sweet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Buildg(3
MOwner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldnits_ Other ❑ Specify:
Brief Description of Proposed Work-: o
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Oflleial Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cosh(item 6)x multiplier x
3. Plumbing $ P 9ther Fees: .S
d.Mechanical (I-IVAC) S List:
5. Mechanical (Fire S Total All Fees:S-
Suppressiun)
c�D Check No._Check Amount: Cash Amount:_
6.Total Project Cost: 'S 'b OO ❑Paid in Full 0 Outstanding Balance Due:
59-71VT" 4 �i 1
a
6
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Noma of CSL Holder List CSL Type(see below)
No. :md Street Type' `- Description .
, U Unrestricted(Buildings tip to 35,000 cu. It.
R Restricted 1&2 Family Dwelling
Chyfrown,Slate,-LIP M IMIsonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or HIC Registrant Name
No.and Street Email address
_Ci ./_T_ovvn State ZI_P Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Istuance of the building permit.
Signed Affidavit Attached? Yes ..........O No...........❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED W HEN
OWNER'S AGENTOR CONTRACTOKAPPLIES FOR BUILDING PEPNIIT`
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 he y attest under the pains and penalties of perjury that all of the information
contaitte is application is u ad accurate to the best of lay knowledge and understanding.
/3 6
P nt Owne's ur r rth� cd Agent's Name(Electron Signature) Dale
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(1-11C)Program);will nol have access to the arbitration
program or guaranty fund under M.G.L.c. 1 a2A.Other important information on the HIC Program can be found at
%vww.mass.eov:'oca Information on the Construction Supervisor License can be found at www.mass.govldos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) s .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Ntmnber of decks/porches
Type ofcoolingsystem Enclosed Open
i. "Total Project Square Footage"may be Substituted fur`'Conan Project Cost"
CITY OF SALEM, MASSACMETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET,38D FLOOR
hr TEL. (978) 745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS STTIERRE
DIRECTOROF PUBLIC PROPERTY/BUILDING CON SIISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE�PRRIN
Date 7 �✓7 I \
Job Location 33 �u
/ -('•S(L rt, cs &1L°� MR
Home Owner Address i, /Scr V I
Present Mailing Address 32�1u Klsr,44�V • s �
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as'supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one•or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR --
CITY OF SALEM, IVMASSAaiUSEM
1 _ BU LD7NG DEPARTMENT
120 WASHINGTONSIREET,3ADRooR
ItL.(978)745-9595
KMERLEYDRISGOLL FAX(978)740-9846
MAYOR TrIOMAS STnERRE
DIRECTOR OF PUBucpROPERTY/BUII.DING Oc)m&ssIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL 00, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
�< e
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
AZ
Siggne applicant
Date